Summary Report for FSPSAs Ending During the Report Period Statewide
This report shows the total number of units/fees for FSPSAs ending during the report period.
(i.e., end date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs ending between: 07/01/09 and 09/30/09 Date of Report: 11-16-09 Page: 1
Child has a MEDICAID # Filter: Y
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
IFSP -IFSP INDIVIDUALIZED FAMILY SUPPORT PLAN 11 11 3.99 $0.00 $0.00
SCTT -SCTT SERVICE COORDINATOR TRAVEL 3 3 10.29 $380.57 $37.00
TCM -T1017TL TARGETED CASE MANAGEMENT 4 4 3.86 $142.71 $37.00
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Subtotal (Total Children Is Unduplicated) 16 18 18.14 $523.28 $28.85
Screening, Eval, and Assessment, Class # 02
ASTE -ASTE ASSISTIVE TECHNOLOGY EVAL 34 37 38.71 $1877.64 $48.50
AUD -92626 EVAL OF AUD REHAB STATUS 2 2 2.00 $72.14 $36.07
AUDE -92552 PURE TONE AUDIOMETRY -AIR ONLY 53 53 54.00 $573.48 $10.62
AUDE -92553 PURE TONE AUDIOMETRY AIR & BONE 1 1 1.00 $16.30 $16.30
AUDE -92555 SPEECH AUD THRESHOLD (DETECTION) 55 55 55.07 $486.24 $8.83
AUDE -92567 TYPMANOMETRY (IMPEDANCE TESTING) 56 56 56.07 $605.52 $10.80
AUDE -92579 VISUAL REINFORCEMENT AUDIOMETRY 55 55 55.07 $1199.90 $21.79
AUDE -92585 AUD EVOKED RESPONSE (DIAG) 2 2 1.07 $58.01 $54.38
AUDE -92587 OTOACOUSTIC EMISSIONS (LIMITED) 27 27 27.00 $763.56 $28.28
AUDE -92588 OTOACOUSTIC EMISSIONS (COMP) 1 1 1.00 $31.81 $31.81
AUDE -AUDE UNSPECIFIED AUDE SERVICES 154 159 160.38 $9622.66 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 12 13 14.00 $655.20 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 104 104 117.08 $14002.31 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 10 11 33.71 $4214.29 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 10 10 10.00 $1250.00 $125.00
EVAL -EVAL DEVELOPMENTAL EVALUATION 35 36 64.68 $3233.93 $50.00
EXIT -EXIT TRANSITION ASSESSMENT 121 127 254.75 $12737.50 $50.00
FANE -FANE FAMILY INTERVIEW BY COMMUNITY PROVI 3 3 3.00 $90.00 $30.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 2 2 3.00 $225.00 $75.00
IPDEF -T1024GNTS F/U PSYCH AND DEV EVAL BY SPAT 21 21 33.00 $2475.00 $75.00
IPDEF -T1024GOTS F/U PSYCH AND DEV EVAL BY OT 9 9 15.00 $1125.00 $75.00
IPDEF -T1024GPTS F/U PSYCH AND DEV EVAL BY PT 4 4 4.50 $337.50 $75.00
IPDEF -T1024TLTS F/U PSYCH AND DEV EVAL BY EI PROF 18 19 25.00 $1875.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 23 23 31.50 $1748.25 $55.50
IPDEI -IPDEI_NM INITIAL PSYCH & DEV EVAL BY NON-MED 9 9 17.50 $971.25 $55.50
IPDEI -T1024GNUK INITIAL PSYCH AND DEV EVAL BY SPAT 339 339 521.20 $39090.01 $75.00
IPDEI -T1024GOUK INITIAL PSYCH AND DEV EVAL BY OT 69 69 124.50 $9337.50 $75.00
IPDEI -T1024GPUK INITIAL PSYCH AND DEV EVAL BY PT 86 86 130.00 $9750.00 $75.00
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 303 303 454.07 $25200.70 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 246 267 372.64 $27948.22 $75.00
NUTR -NUTR UNSPECIFIED NUTRITIONAL EVAL 3 3 3.00 $150.00 $50.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 57 58 57.08 $2768.54 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 365 394 421.04 $20420.24 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 61 62 60.94 $2955.61 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 295 313 333.60 $16179.36 $48.50
SCREEN-T1023 INTERDISCIPLINARY SCREENING 10 10 10.00 $500.00 $50.00
SPCH -92506 SPEECH EVAL BY LICENSED SLP 692 746 760.50 $36884.48 $48.50
VISF -VISF VISION EVALUATION FUNCTIONAL 5 5 5.50 $275.00 $50.00
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Subtotal (Total Children Is Unduplicated) 2105 3494 4332.15 $251707.15 $58.10
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 40 53 69.00 $103500.00 $1500.00
AUD -92633 AUD REHAB POSTLING HEARING LOSS 1 1 3.14 $216.42 $68.86
AUD -HA_FUP AUDIOLOGY SERVICES 44 45 103.04 $5152.14 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 349 486 780.57 $39028.33 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 12 12 8.50 $212.50 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 729 782 1240.09 $62004.41 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 36 38 55.34 $1383.48 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 329 352 488.68 $24433.88 $50.00
CONOP -CONOP CONSULT, OT, PHONE 7 8 9.34 $233.61 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 272 280 416.66 $20832.78 $50.00
CONPP -CONPP CONSULT, PT, PHONE 10 10 23.55 $588.73 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 716 774 1116.36 $55818.25 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 45 47 81.62 $2040.45 $25.00
COUN -H2019HR INDIVIDUAL/FAMILY THERAPY 11 11 86.71 $6366.56 $73.42
ECE -ECE EARLY CHILDHOOD EDUCATION 7 7 298.00 $3725.00 $12.50
EIGF -EIGF_NM EI GROUP SESSION BY NONMED PROF 1 1 0.43 $10.83 $25.00
EIGF -T1027TTSC EI GROUP SESSION BY EI PROF 205 227 1465.72 $36642.98 $25.00
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 4 4 52.14 $2607.14 $50.00
EIIF -COUN UNSPECIFIED COUNSELING 1 1 1.00 $50.00 $50.00
EIIF -EIIF_NM EI INDIVIDUAL SESSION BY NONMED PRO 6 6 58.57 $2928.57 $50.00
EIIF -T1027HM EI INDIVIDUAL SESSION BY PARAPROF 1 1 11.43 $285.72 $25.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 2432 2760 16098.55 $804927.57 $50.00
HERN -EIIF_NM EI HEARING SERVICES AFTER SHINE NON 12 12 21.08 $1053.85 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 38 55 394.95 $19747.58 $50.00
INTR -INTR INTERPRETER 103 115 517.49 $25874.30 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 1064 1230 6407.33 $434929.68 $67.88
OCCT -97530HM OT SESSION BY OT ASST 43 43 244.75 $13294.71 $54.32
PHY -97110 PT SESSION BY LICENSED PT 1289 1479 7166.83 $486484.39 $67.88
PHY -97110HM PT SESSION BY PT ASST 39 42 224.57 $12198.84 $54.32
RSPT -RSPT RESPITE 1 1 25.60 $0.00 $0.00
SCONLY-SCONLY SERVICE COORDINATION ONLY 267 275 282.74 $282.74 $1.00
SENS -FM FM RECEIVER HEARING AID 1 1 1.00 $1650.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 5 5 9.00 $4500.00 $500.00
SENS -HA_INS SENSORY AID INSURANCE PER EAR 2 2 3.00 $195.00 $65.00
SENS -V5050 MED HEARING AID - ANALOG/DIGITAL 5 5 9.00 $2134.08 $237.12
SENS -V5264 EARMOLD 25 26 44.05 $824.56 $18.72
SHIN -EIIF_NM INITIAL SHINE SERVICES, IND NONMED 1 1 4.60 $230.00 $50.00
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 46 53 198.78 $9938.82 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 2163 2468 12451.80 $845228.26 $67.88
SPL -92507HM SPL THERAPY SESSION BY SLP ASST 2 2 7.86 $426.80 $54.32
SPL -92508 GROUP SPL SESSION PER CHILD 115 122 572.97 $7563.18 $13.20
TRAN -TRAN FAMILY TRANSPORTATION 4 4 15.01 $1500.96 $100.00
TRAV -TRAV PROVIDER TRAVEL TO NATURAL ENVIRONM 1754 2422 249990.22 $124995.11 $0.50
VISN -EIIF_NM EI VISION SERVICES, IND NONMED 2 2 12.60 $630.00 $50.00
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 52 65 266.28 $13314.17 $50.00
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Subtotal (Total Children Is Unduplicated) 5199 14336 301339.95 $3179986.32 $10.55
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Total 17848 305690.23 $3432216.75 $11.23
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Number of Children (Unduplicated) With at Least One Authorization 5901